Training Aphasia Patients to Speaker Introduction/Disclosures Provide Their Own Internal No relevant financial or nonfinancial relationships to disclose. Cues: Two Case Studies L. Katherine Stewart, MS, CCC-SLP

What is aphasia? ❖ An impairment in expression and/or comprehension of spoken and/or written language ❖ Currently affects over 2 million Americans ❖ Most common etiology is stroke ❖ Left hemispheric dominance (usually) ➢ Frontal lobe: praxis, high-level syntax comprehension ➢ Parietal lobe: integration of information, association, repetition ➢ Temporal lobe: comprehension, phonological processing, linguistic memory Common naming errors in aphasia Ellis & Young (1988) model of language processing ❖ Anomia: “They’re getting food out of their picnic...I can’t think of the word.” ❖ Paraphasias ➢ Semantic: “That’s a picnic bag.” ➢ Phonemic: “They have a picnic gasket.” ➢ Neologism: “Here’s a flickstag.” ❖ Perseveration: “That’s a blanket, and they get food out of their blanket.” ❖ Circumlocution: “They’re doing...where you put food on a blanket on the ground.” ❖ Conduit d’approache: “That’s their picnic pack...pask...basp…”

Types of cues to aid word retrieval Problems with external cueing ❖ Phonemic: “Ba...” or “bas...” ❖ Reduced independence of communication ❖ Semantic: “It’s woven from wicker, and has handles.” ❖ Communication partners often naive to target word ❖ Gestural: (mime carrying/opening basket) ❖ These issues still apply to AAC/total communication ❖ Cloze: “A tisket a tasket, a green and yellow…” approach “Internal” cueing? Patient A: Case History Two patients treated at hospital outpatient clinic ❖ 66-year-old female ❖ PMH: HTN, HLD, anxiety/depression, arthritis, essential ❖ Different aphasia classifications tremor, cataracts, and glaucoma ❖ Both aware of errors ❖ Retired hairstylist; cosmetology school education ❖ Both demonstrated favorable response to external cueing ❖ Presented to ED at local hospital; GLF and AMS with R weakness ❖ Admitted, stroke workup > d/c to subacute rehabilitation >d/c home two weeks later

Patient A: Findings at Initial Outpatient Assessment Patient A: Neuroimaging Findings ❖ Boston Diagnostic Aphasia Examination (Short Form) ➢ Auditory Comprehension - relatively strong Brain MRI: early subacute infarct involving left posterior ➢ Conversational and Expository Speech frontal and parietal lobes in the left middle cerebral artery ■ Fluent with preserved sentence structure and prosody with predominantly phonemic paraphasias (MCA) territory, with small hemorrhagic component ➢ Oral Expression* ■ Automatized Sequences: 33% accuracy ■ Repetition: 70% accuracy for single words, 20% accuracy for sentences ■ Responsive Naming: 71% accuracy ❖ Boston Naming Test (Short Form) ➢ Confrontation Naming* ■ 7% accuracy independently ■ 40% accuracy given phonemic cues ■ 87% accuracy given 4 written choices Patient A: Continued Results of Initial Outpatient Patient A: Deficits and Strengths Evaluation

❖ Boston Diagnostic Aphasia Examination (Short Form) DEFICITS STRENGTHS ➢ Reading ❖ Phonemic paraphasias ❖ Comprehension (auditory and ■ Basic Symbol Recognition: 75% accuracy (typically nonwords) in reading) ■ Picture-Word Match: 75% accuracy naming tasks, oral reading, ❖ Fluency/praxis and ➢ Writing - not administered due to time constraints at initial evaluation spontaneous speech, and grammaticality

repetition ❖ Awareness of errors; conduit

d’approache Recommendation: Speech therapy twice weekly for 4-8 weeks Profile is most consistent with conduction aphasia!

Patient A: Where is the naming impairment? Patient A: “Internal” phonemic cueing?

❖ Phonemic paraphasias primarily substitutions of initial phonemes (e.g., “froke” for “stroke”); at minimum, syllable nuclei (e.g., vowels) strongly resembled the target word (e.g., “yunt” for “hunch”). ❖ Able to produce the target word given a phonemic cue (i.e., initial phoneme) from another person ❖ Existing treatment: phonological components analysis (PCA; Leonard et al, 2008) ❖ Could explicit training in phonological skills enable her to provide phonemic cues to herself? ??? University of Arizona Aphasia Project (Beeson) ❖ Evidence that most perisylvian aphasia patients (such as Broca’s, Where does Patient A fit? Wernicke’s, conduction, and global) have poor phonological skills ➢ Alexia - reading impairment ❖ Arizona Battery of Reading and Spelling ➢ Agraphia - writing impairment ➢ Reading: 33% overall accuracy ❖ A treatment sequence was designed to rehabilitate written language ■ 3/10 high frequency/phonologically regular skills, which could also be used as “prerequisite” for training ■ 6/10 low frequency/phonologically regular self-cueing for spoken lexical retrieval ■ 1/10 high frequency/phonologically irregular ■ 3/10 low frequency/phonologically irregular ❖ Arizona Battery of Reading and Spelling ➢ Spelling (writing to dictation): 50% overall accuracy ➢ Phonological agraphia - >80% accuracy on spelling portion, predominantly ■ 4/7 high frequency/phonologically regular phonological impairments, more difficulty with low-frequency words and nonwords ■ 5/9 low frequency/phonologically regular ➢ Global agraphia - <80% accuracy on spelling portion, lexical/semantic and ■ 3/7 high frequency/phonologically irregular orthographic as well as phonological impairments, difficulty with all types of stimuli ■ 3/7 low frequency/phonologically irregular

<80% accuracy on spelling = start with lexical/semantic treatment

Lexical/Semantic Treatment (Beeson) Phonological Treatment (Beeson) Copy and Recall Treatment (CART) ❖ When patient able to read and write/spell the “key” words (trained via CART if applicable), move on to explicit phonological training (typically consonants first, ❖ Goal: to strengthen/retrain spellings of specific words (can be standard set then vowels): and/or personally relevant words for patient) - semantic system and ➢ Sound-letter correspondence phonological output lexicon ➢ Letter-sound correspondence ➢ More advanced tasks, including but not limited to: ❖ Prerequisite for phonological treatment ■ Blending ❖ Can also establish “key words” to use in next step (i.e., phonological ■ Segmenting treatment) ■ Matching ❖ Homework every session ■ Phonemic generative naming ❖ Specific protocol and standard stimuli available on ■ Rhyme judgment ❖ Traditionally followed by interactive spelling treatment (independent error https://aphasia.arizona.edu/ correction) ❖ Full protocol and more information available on https://aphasia.arizona.edu/ Patient A: Treatment Sequence Patient A: End Results ❖ Lexical-semantic treatment to prepare for phonological treatment ❖ Self-discharged after 6 weeks of therapy (satisfied with progress) ➢ 7 sessions before beginning to “mix” phonological treatment in; 10 ❖ Phonological components analysis (PCA) introduced as compensatory sessions total strategy ➢ Personally relevant stimuli: “orange,” “help,” “pain,” “stroke,” “mail,” “water,” “steak,” “phone” ➢ From standard Beeson stimuli: “dog,” “hat,” “net,” “top,” “van,” “web,”

“pie,” “bone,” “cake,” “goat,” “safe,” “fire,” “rug,” “ship,” “moon,” “zoo,” “chin,” “judge” ❖ Phonological treatment ➢ 4 sessions total (3 “mixed” with lexical-semantic) ➢ Reached 100% accuracy for letter-sound and 80% accuracy for sound-letter for (/p/, /b/, /k/, /s/, /g/, /f/) ➢ Reached 90% accuracy for letter-sound and 90% accuracy for sound-letter for (/r/, “sh,” /m/, /z/, “ch,” “j”) www.tactustherapy.com

Patient A: Reassessment Patient C: Case History Initial Evaluation Final Session

BNT short form - ❖ 69-year-old female

independent accuracy 7% 40% ❖ PMH: HTN, HLD, anxiety, osteoporosis, thyroid disease, and BNT short form - with lumbar osteoarthritis 40% 53% phonemic cues ❖ Worked as a substitute teacher BNT short form - with 4 ❖ Arrived at local hospital ED via EMS with R weakness, R facial written choices 87% 100% droop, and inability to speak Picture description Phonemic paraphasias, Able to self-correct all anomia, circumlocutions, phonemic paraphasias except ❖ Head CTA: large clot in M3 segment of MCA empty speech one ❖ tPA administered > transferred to comprehensive stroke center > d/c to acute inpatient rehabilitation > d/c home Patient Findings from Initial Outpatient Evaluation Patient C: Neuroimaging Findings ❖ Boston Diagnostic Aphasia Examination (Short Form) ➢ Auditory Comprehension - relatively strong ➢ Conversational and Expository Speech Brain MRI: small to moderate volume of water restriction on ■ Non-fluent with agrammatism, apraxia of speech diffusion-weighted imaging involving the left posterior frontal and perirolandic ➢ Oral Expression* cortex and subcortical white matter, compatible with a recent left MCA ■ Automatized Sequences: 25% accuracy ■ Repetition: 20% for single words, 50% for sentences distribution infarct ■ Responsive Naming: 20% accuracy ➢ Reading ■ Basic Symbol Recognition: 100% accuracy ■ Picture-Word Match: 100% accuracy ➢ Writing ■ Mechanics of Writing: 100% accuracy ■ Basic Encoding Skills (dictated words): 100% accuracy ❖ Boston Naming Test (Short Form) ➢ Confrontation Naming* ■ 13% accuracy independently

Patient C: First Month of Outpatient Therapy Patient C: Deficits and Strengths ❖ Recommendation: Speech therapy three times weekly for 8-12 DEFICITS STRENGTHS weeks ❖ Fluency/praxis, grammaticality, and information content of ❖ Nonfluent, often agrammatic ❖ Auditory comprehension and speech reading comprehension spontaneous speech improved ❖ Apraxia ❖ Written expressive ❖ Lexical perseverations and semantic paraphasias began to ❖ Perseverations (and less language/spelling and ability to predominate frequently, non-perseverative use low-tech AAC (letter and

❖ Although written naming initially impaired at evaluation, dramatically semantic paraphasias) in number board) naming tasks, spontaneous ❖ Awareness of 90-100% of improved in first month of therapy speech, repetition, and oral paraphasias/perseverations ➢ Used notebook and pencil as a low-tech AAC method (mostly for reading

single words) using left non-dominant hand ➢ Able to point to letters and numbers on low-tech AAC alphabet Profile is most consistent with ???? aphasia? board to spell words (even when unable to verbalize them) ➢ Written language skills at the sentence level determined to be WFL after ~1 month Patient C: “Internal” cueing? Patient C: Where is the naming impairment? ❖ Naming errors only in verbal lexical selection/retrieval ❖ Would respond to external cloze cues, occasionally with a phonemic cue ❖ Due to possible promising results for Patient A 2 years earlier, phonological treatment initiated

Patient C: Phonological Treatment Sequence ❖ Lexical-semantic treatment deemed unnecessary due to high baseline Aphasic Perseverations: Possible Explanations spelling accuracy. ❖ Initiated Beeson’s phonological treatment protocol ❖ “Pseudo-apraxia” (Pick, 1892) ➢ 6 sessions to train all phonemes in the protocol (consonants and vowels) ❖ Perseveration fills in the “gap” due to the underlying language impairment ➢ Most difficulty with /z/, "sh," and "ch" consonants, as well as vowel phonemes (Heilbronner; Lissauer) ➢ Reached criterion (80-100%) for sound-letter awareness of all phonemes ❖ “Over-activation” of previous response (von Solder) ➢ Reached criterion for letter-sound when vowel approximations were accepted (distorted due to apraxia) ❖ “Under-activation” of intended response (Pick) ❖ Probed ability to “self”-cue after the 6 sessions ❖ Too little input for intended response and too much activity/activation from a ➢ Patient C still required external cueing (e.g., “Remember your key word for this sound”) previous trial - at multiple levels of language processing (Cohen and ➢ Also often required a (self) written model Dehaene) ➢ Phonological components analysis (PCA) more helpful, but still not efficient and required external cueing ❖ Her tendency towards perseveration had not significantly changed (even with written models)...why? Semantic Feature Analysis (SFA) for Nouns ❖ Theory: by activating semantic information “surrounding” a target word, higher Alternative “internal” cueing strategy for Patient C? likelihood the target will be activated ❖ First described by Ylvisaker & Szekeres in 1985 ❖ Despite inconsistent success with self-cueing, reported ❖ More detailed research by Mary Boyle that phonological treatment had been helpful ➢ 1995 single-subject case study with Carl Coelho: use of graphic organizer with nonfluent aphasia; positive effects generalized to confrontation naming of untrained stimuli, but no ❖ Independently began attempting to self-cue aloud change in connected speech

(automatic speech and cloze cues) ➢ “14, 15, 16” for target word of “sixteen” ➢ “Pots and pans” for target word of “pan” ❖ Would she be better served by a semantic approach to supplement phonological approach?

Semantic Treatment for Patient C: Nouns ❖ Relatively strong baseline semantic skills, minimal-to-no naming impairments in written language Patient C: Beyond nouns? ❖ 4 formal sessions (some concurrent with phonological treatment and/or ❖ Dysfluency, occasional agrammatism, and reduced MLU/information content additional semantic approach to be described later) targeting use of graphic continued to negatively impact effectiveness of spoken language organizer with emphasis on speaking each attribute aloud as a “self” cloze ❖ Confrontation naming of verbs probed during a session where SFA was being cue (motor priming for “pseudo-apraxia”?) targeted ➢ E.g., “sit at the table,” “kitchen table,” “table and chairs” ➢ 40% accuracy independently ➢ Able to retrieve and produce target words in 90-100% of opportunities (i.e., when ➢ Increased to 100% accuracy when encouraged to create a sentence given information from causing difficulty) during sessions picture scene (i.e., agent and patient) ❖ Best way to train Patient C to do this independently? Semantic Treatment for Patient C: Verbs/Sentence Verb Network Strengthening Treatment (VNeST) Structure ❖ First proposed by Lisa Edmonds (2009) ❖ Inspired by VNeST; modified approach ❖ Protocol: ❖ 6 formal sessions (some concurrent with SFA treatment) targeting use of verb-centered ➢ Given one verb, generate 3 agent-patient pairs graphic organizer to create detailed sentences ➢ Answer “wh” questions about one pair ❖ Unlike in original VNeST protocol, specific stimuli provided ➢ Semantic judgment of SLP-created sentences using the trained verb ➢ Line drawings of scenes ❖ Generalization to confrontation naming of untrained nouns and verbs ➢ Later written prompts (e.g., “I saw…”) ❖ Reached 80-85% accuracy independently/verbally, increasing to 100% given self written cues ❖ Eventually able to “mentally” picture graphic organizer for independent use

https://tactustherapy.com/vnest-verb-network-strengthening-app/

Patient C: Reassessment Patient C: End Results ❖ Continued therapy on a tapered schedule (twice a week, once a week, twice a Initial evaluation After 8 total weeks of therapy (4 month, once a month) for 5 more months (total of 7 months; 48 visits) weeks of “self-cueing” training) ➢ Later sessions focused upon independent use of self-cueing strategies in conversation-level tasks BNT short form - independent ➢ Patient C benefited from a combination of all approaches (phonological, semantic with 10% 67% accuracy noun focus, and semantic with verb focus) ❖ Picture description (“cookie “Dishes, food, water. Family “In this picture, uh, the, uh, lady is At time of discharge, independently self-correcting 90-95% of communication theft”) fight. Girl, boy.” uh…(unintelligible) let me breakdowns, with continued but less frequent use of notebook for low-tech see...uh...cleaning the dishes. Uh, the water is on the floor. Uh, um, the AAC boy...the boy and the girl…ta-...let’s ❖ Still with limited socialization outside her home, and not interested in returning see...taking the ha...I’m sorry. The uh, um, boy...the girl, and the girl are to work, due to circumstances surrounding COVID-19 pandemic taking the cookie jar. Um, the little boy is going to, uh, fall in the chair. It’s not a chair...stool.” “Internal” cueing: Possible conclusions ❖ Implications of cases of Patient A and Patient C: Questions/Comments? ➢ Awareness of errors and attempts at self-correction prior to treatment = positive prognostic indicator for “internal” cueing [email protected] ➢ Promising results for “internal” cueing for mild-moderate phonemic paraphasias, semantic paraphasias, lexical perseverations, and agrammatism ➢ Possible bidirectional connections in Ellis & Young model, including between: ■ Sound-letter/letter-sound awareness and phonological output buffer ■ Phonological output buffer and phonological output lexicon ■ Phonological output lexicon and semantic system ➢ Possible support for Pick’s “pseudo-apraxia” theory of verbal perseverations ➢ “Internal” cueing training should be considered for aphasia patients with post-semantic impairments ❖ Areas for further study: ➢ “Internal” cueing for semantic impairments, and/or comprehension impairments? ➢ Possible similar training for primarily orthographic impairments?

References References

Beeson, P. (Producer). (2017). Treatment sequences to maximize recovery from aphasia [PowerPoint Leonard, C., Rochon, E., & Laird, L. (2008). Treating naming impairments in aphasia: Findings from a slides and video]. phonological components analysis treatment, Aphasiology, 22:9, 923-947, DOI: https://www.barrowneuro.org/wp-content/uploads/Beeson-2018-Barrow-handout.reduced.pdf 10.1080/02687030701831474

Boyle, M., & Coelho, C. A. (1995). Application of semantic feature analysis as a treatment for aphasic National Aphasia Association (Ed.). (2020, September 09). What is aphasia? Retrieved November 14, dysnomia. American Journal of Speech-Language Pathology, 4(4), 94-98. 2020, from https://www.aphasia.org/

Edmonds, L. A., & Babb, M. Effect of Verb Network Strengthening Treatment (VNeST) on Lexical Retrieval Stark, J. (2017). Perseveration: Clinical Features and Considerations for Treatment. In Coppens, P., & in Sentences in Moderate-Severe Aphasia. Age, 42, 49. Patterson, J. (Eds.). Aphasia Rehabilitation: Clinical Challenges (pp. 3-45). Burlington, Massachusetts: Jones & Bartlett Learning, LLC. Ellis, A.W. & Young, A.W. (1988). Human Cognitive Neuropsychology. Hove, UK: Erlbaum. Tactus Therapy Solutions Ltd. (2020, January 30). How To: VNeST - Verb Network Strengthening Gvion, A. & Friedmann, N. (2012) Phonological short-term memory in conduction aphasia, Aphasiology, Treatment for Aphasia. Retrieved November 14, 2020, from 26:3-4, 579-614, DOI: 10.1080/02687038.2011.643759 https://tactustherapy.com/vnest-verb-network-strengthening-app/

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